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Back Pain in Children

Back pain and kids because this is something that does present in our office. This is the differential diagnosis of things to think of in kids back pain. Until kids get to be teenagers, they donít get things like herniated discs and the typical adult sort of problems, so if you have a child that comes in complaining of back pain, these are the things to go through in your mind to try and rule out. I am going to go through them in the order they are in your outlines, rather than the order I have them on this.

The first thing to think of is spondylolysis. This is a defect in the pars interarticularis area of the vertebrae and itís common in gymnasts and weight lifters, it can be a congential weakness that fractures and is diagnosed usually with radiographs and bone scans. The way we describe this, itís always a little goofy the first time you hear it, but this is an oblique view of the L5-S1 area and we call this the Scottie dog. If you look here, this is the snout, these are the ears, this is his neck and these are his front paws, here is his body back here.

The Scottie dog has a collar, and the Scottie dog is not supposed to have a collar. If he has a collar here, thatís a fracture, and that fracture is best seen on the lateral views rather than on the AP view. Here is the other side of the same patient. Again, you see the snout, the ears, the neck, front legs down here, but he has a collar here. This tells you that he has a defect, itís almost always the L5 vertebrae, occasionally the L4 but almost always L5 and he has a defect here. Itís still possible the defect has been there since he was born or for a couple of years and may not be causing his pain, so we do usually get bone scans and this doesnít project quite as well, but the bone scans that they can get now can give you tomographic cuts with the SPECT scans, this is actually very hot right in here, it corresponds exactly anatomically with the area.

The bone scan is going to be hot for nine months after the onset of the fracture, so if you have a fracture, bone scans will stay hot for a good nine months afterwards. This will tell you that this is less than nine months old, so itís an acute problem, therefore we would go ahead and treat it. The bone scan is not very good to tell you whether itís healed or not because it stays hot for so long. The treatment for the spondylolysis is usually a brace, we can usually get people to heal up, we usually brace them for about four months. Our experience is that most people get back to their previous level of activities with that treatment, if they donít bet better then we can surgically repair that area, but it hasnít been very common that anybody has needed it. The prognosis is fairly good with the brace, the patientís will get back to their previous level of activities but itís going to be six months or so before

Spondylolisthesis and when that occurs, that space where the fracture was expands and the front and back part of the spine separate from each other and then the front part of the spine starts to come forward on S1. So here, L5-S1 you can see the anterior line comes down here then it jumps back to here. So the nerves are coming down out here and then draped over the back of S1. This is probably congenital because this looks like there may be some bone here thatís intact. This is a congenital spondylolisthesis, and these can be associated with pinching of the nerve roots here and can be very painful. If this slides far enough, then we have to fuse it together. If we fuse these two together or these three together, the movement there and the pressure on the nerves will often end, the treatment we have to decide on, but this is one of the things you are looking for and the reason we get a lateral view is to see if the patient has this listhesis. Sometimes if the listhesis is bad enough, you will need surgery even if youíre not having a lot of symptoms because essentially you are guaranteed to get symptoms later on. Here is one thatís a little more subtle, but you can still see this comes down and then there is a step-off back to

This is a grade I, this doesnít necessarily need surgery if itís a grade I, but it this slips 50% or more, then you have to fuse it, and can actually slide all the way out the front, and the operations to fix that are associated with a high degree of sexual dysfunction afterwards, so they are not very much fun and we try not to let them get that far. Again, 30% slip can we watched, 50% we fuse in situ and over 50% you have some reduction and some sort of

Here is an example of a spinal listhesis, and again, if you look for the Scottie dog, he not only has a collar, but the back of his neck is way up here instead of back here. The radiologists know about this and will usually pick this out and will be able to show you on the x-rays. This is another thing that can cause back pain, Shoremanís disease, this is that kyphosis that we saw earlier, three vertebrae wedged 5 degrees is the strict definition, it seems that patientís are painful because the muscles get tired of trying to hold the patient up when youíre bent over

If the patient still has growth to go, this is the one situation where the Milwaukee brace is nearly 100% effective in actually getting a person to grow straight and eliminate the pain. In people who are fully grown, it will eliminate the pain, but obviously they wonít grow straighter since they have already finished growing. We can also treat this with stretching exercises active and passive to try and get the patientís posture a little bit better. Rarely does that need surgery, and I have seen two people with that in 11 years that have needed surgery for it.

Discitis. This is back pain that presents usually with normal x-rays, the pain can be present for months and can be a very low grade infection back pain, backache, back ache, sore back. Itís usually staph. The sed rate will usually be elevated, the bone scan is uniformly going to be hot if you have this. The first thing to do is get a sed rate, if itís normal, then it kind of makes it hard for it to be discitis. Here is an example, this is a little narrowed compared to the other one not noticed at the time but in